Excerpt

The most successful health care systems offer ready access to high-quality primary care—an approach that is embedded in the fundamental design of Veterans Affairs (VA) health care and which is consistent with the Institute of Medicine’s definition of high-quality care. This definition emphasizes safe, effective, patient-centered, timely, efficient, and equitable health care. Group medical visits are a method to deliver health care that offers the promise of improving these aspects for patients with chronic conditions.

Group visits (or clinics) are a system redesign in which clinicians see multiple patients together in the same clinical setting. Shared medical appointments (SMAs) are a subset of such clinics and are defined by groups of patients meeting over time for comprehensive care for a defining chronic condition or health care state. SMAs usually involve both a person trained or skilled in delivering patient education or facilitating patient interaction and a practitioner with prescribing privileges. SMA sessions typically last 60 to 120 minutes, with time set aside for social integration, interactive education, and medication management, in an effort to achieve improved disease outcomes.

SMAs have been scientifically tested in an array of primary care settings over the last 10 to 15 years. However, there has been great variability among these studies in relation to setting; components included in the intervention; and measurement of clinical, cost, and utilization outcomes. For example, the patient group may stay constant, in an attempt to provide group bonding, or the patients may be allowed to choose sessions from a schedule at their convenience to promote attendance. Like patients, provider teams can be constant or vary over time. This uncertainty regarding the optimal design and impact of SMAs led the VA to commission this evidence synthesis report.

Our objective was to summarize the effects of SMA on staff, patient, and economic outcomes and to evaluate whether the impact varied by clinical condition or specific intervention components.

Contents

• PREFACE
• EXECUTIVE SUMMARY
  • BACKGROUND
  • METHODS
  • DATA SYNTHESIS
  • RATING THE BODY OF EVIDENCE
  • PEER REVIEW
  • RESULTS
  • RECOMMENDATIONS FOR FUTURE RESEARCH
  • CONCLUSION
  • ABBREVIATIONS TABLE
• INTRODUCTION
  • BACKGROUND
  • OBJECTIVE OF THIS REPORT
• METHODS
  • TOPIC DEVELOPMENT
  • ANALYTIC FRAMEWORK
  • SEARCH STRATEGY
  • STUDY SELECTION
  • DATA ABSTRACTION
  • QUALITY ASSESSMENT
  • DATA SYNTHESIS
  • RATING THE BODY OF EVIDENCE
  • PEER REVIEW
• RESULTS
  • LITERATURE FLOW
  • STUDY CHARACTERISTICS
  • KEY QUESTION 1 For adults with chronic medical conditions, do shared medical appointments (SMAs) compared with usual care improve the following outcomes?
  • KEY QUESTION 2 For adults with chronic medical conditions, do the effects of SMAs vary by patient characteristics (e.g., specific chronic medical conditions and severity of disease)?
  • KEY QUESTION 3 Is the intensity of the intervention or the components used by SMAs associated with intervention effects?
• SUMMARY AND DISCUSSION
  • SUMMARY OF EVIDENCE BY KEY QUESTION
  • CLINICAL AND POLICY IMPLICATIONS
  • STRENGTHS AND LIMITATIONS
  • RECOMMENDATIONS FOR FUTURE RESEARCH
• REFERENCES
• APPENDIX A SEARCH STRATEGIES
• APPENDIX B EXCLUDED STUDIES
• APPENDIX C DATA ABSTRACTION ELEMENTS
• APPENDIX D CRITERIA USED IN QUALITY ASSESSMENT
• APPENDIX E PEER REVIEW COMMENTS
• APPENDIX F ONGOING CLINICAL TRIALS
• APPENDIX G SMA STUDY CHARACTERISTICS
• APPENDIX H SMA INTERVENTION COMPONENTS
• APPENDIX I GLOSSARY

Medical Editor: Liz Wing, MA

Prepared for: Department of Veterans Affairs, Veterans Health Administration, Quality Enhancement Research Initiative, Health Services Research & Development Service, Washington, DC 20420. Prepared by: Evidence-based Synthesis Program (ESP) Center, Durham Veterans Affairs Healthcare System, Durham, NC, John W Williams Jr., M.D., M.H.Sc., Director.

Suggested citation:

Edelman D, McDuffie JR, Oddone E, Gierisch JM, Nagi A, Williams JW Jr. Shared Medical Appointments for Chronic Medical Conditions: A Systematic Review. VAESP Project #09-010; 2012.

This report is based on research conducted by the Evidence-based Synthesis Program (ESP) Center located at the Durham VA Medical Center, Durham, NC, funded by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative. The findings and conclusions in this document are those of the author(s) who are responsible for its contents; the findings and conclusions do not necessarily represent the views of the Department of Veterans Affairs or the United States government. Therefore, no statement in this article should be construed as an official position of the Department of Veterans Affairs. No investigators have any affiliations or financial involvement (e.g., employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties) that conflict with material presented in the report.